Medicating alcohol problems shouldn’t mask moralising about ‘good’ and ‘bad’ drinking

Nalmefene for the soul? Larepuvlica, CC BY-NC

The use of nalmefene to reduce alcohol consumption was recently endorsed by the National Institute for Health and Care Excellence (NICE). Nalmefene is a drug that is used to incrementally reduce cravings for alcohol. NICE recommends it is used, alongside psychosocial treatments such as counselling, to treat people regarded as dependent on alcohol.

This raises a number of interesting issues, not only the usual ones about cost and effectiveness, but also how conclusions are drawn between what constitutes “good” and “bad” drinking.

NICE categorises certain forms of drinking as sufficiently problematic to warrant medication and others as not. This amounts to a normative distinction – a statement about how people should and should not behave. As such, it is important to consider this recommendation in relation to these “good” and “bad” forms of drinking.

‘Good’ and ‘bad’ drinking

NICE recommends that nalmefene is suitable for men who consume more than 7.5 units per day (about three pints of strong beer) and women who consume more than five units per day (about half a bottle of wine). These levels of consumption exceed the daily units limits suggested by the Department of Health and are classified as “higher risk” by NICE. Higher-risk drinkers then become the targets of behavioural reform initiatives, such as treatment and medication.

But if nalmefene is recommended for this form of “bad” drinking, what constitutes non-excessive, low-risk or “good” drinking?

The official guidance in the UK is that men should not consume more than 3-4 units per day and women no more than 2-3. This guidance is historically and culturally relative. In 1979, for example, the Royal College of Psychiatrists recommended that people limit their alcohol consumption to as many as eight units per day – which, under NICE’s recommendation, would be enough to qualify for a dose of nalmefene today.

Of course, some variation over time might be expected as guidelines react to new scientific knowledge. But, as I have written about before, the evidence base of the current advised units limits is far from solid, which renders the current guidance largely arbitrary. Perhaps for this reason, guidelines on what is an acceptable form of drinking do not just vary through time, they also vary markedly between different countries in the present day.

Historical roots

This confusion about what constitutes a “good” form of drinking has historical roots in the 19th century. In the early 1800s, drink problems in Britain tended to be associated with drunkenness and/or spirits drinking only. Beer drinking, and drinking in a manner not regarded as entailing drunkenness, were seen as morally neutral actions – or even positive actions. In some contexts, beer drinking was associated with strength, patriotism and good character.

Take your pick. Foxtongue, CC BY-NC-SA

Such views were fundamentally challenged from the 1830s onwards by the emergence of teetotal temperance movements in Britain and in a number of other nations (particularly English-speaking and Scandinavian countries). British temperance groups vociferously argued that all forms of drinking produced violence, sickness, poverty and other problems, whereas teetotalism led to health, wealth and personal character. While lots of people rejected their stipulation of abstinence, the teetotallers’ idea that any form of drinking can be problematic was widely accepted in Britain by the early 20th century. Beer-drinking and drinking which did not lead to drunkenness ceased to be widely perceived as morally good or morally neutral during the Victorian period.

Since then, any other notion of a “good” drink or “good” form of drinking has proved elusive. The contemporary trend is towards an increasingly stringent approach to acceptable levels of alcohol consumption. The Department of Health recommended abstinence for pregnant women in 2007; the Royal College of Psychiatrists advised over-65s to consume no more than 1.5 units per day in 2011; and, in August this year, Public Health England advised all drinkers to abstain every other day.

Many public health professionals have also emphasised that all forms or amounts of drinking carry risk. In this context, it is increasingly difficult to ascertain what form of drinking might be considered responsible, acceptable or “good”.

So NICE’s proposals are part of a wider moral discourse about alcohol consumption which comprises vivid normative judgements about what forms of drinking are either high risk or low risk, acceptable or unacceptable, good or bad.

In this sense, nalmefene may be for the soul as much as for the liver. And as NICE recommends medication to treat “bad” drinking, it is pertinent to ask what form of drinking should be encouraged instead? If “bad” is reduced, what is the “good” that is being promoted? Unless abstinence is to be the goal of public health policy in England, there is a pressing need to determine what manner of alcohol consumption should replace the higher-risk forms of drinking that are targeted by various regulatory initiatives. Until this historical gap in British understanding of alcohol consumption is filled, policy discussions about alcohol will remain oddly imbalanced.